What is the purpose of a tracheostomy. To _______.

Correct Answer: A

Rationale: The purpose of a tracheostomy is to establish an artificial airway in the trachea through a surgical procedure. This is done to bypass obstructions in the upper airway, assist with breathing, or facilitate the removal of secretions from the lungs. A tracheostomy helps in maintaining a clear and secure airway for patients who have difficulty breathing or require long-term mechanical ventilation support.

Correct Answer: A

Rationale: The appropriate approach of the nurse in this situation would be to talk about the reality of death with the father. It is important to provide appropriate and compassionate communication, acknowledging the father's grief while also gently guiding him towards accepting the reality of the situation. By discussing the reality of death and offering support, the nurse can help the father start the grieving process and eventually come to terms with the loss of his son. It is important to provide emotional support and guidance in a sensitive and respectful manner during such a difficult time.

Correct Answer: B

Rationale: Delegation by succession involves passing on responsibility and authority to a designated successor when the delegator is temporarily unavailable. In this scenario, the unit manager is planning to take her regular official business leave and has recommended her assistant unit manager to assume her position during her absence. This act follows the principle of succession, where the deputy or next in line is entrusted with the duties and decision-making power of the manager. This ensures a smooth transition of responsibilities and allows the operations to continue efficiently in the manager's absence.

Correct Answer: B

Rationale: Breast tenderness is a hallmark symptom of premenstrual syndrome (PMS), which occurs in the days leading up to menstruation. This symptom is often associated with hormonal fluctuations during the menstrual cycle. Women may experience increased sensitivity and soreness in their breasts, making them feel tender or swollen. It is a common symptom of PMS and can vary in severity from one individual to another. Pelvic pain, postmenopausal bleeding, and dyspareunia are not typically considered hallmark symptoms of PMS.

Correct Answer: D

Rationale: Sonography, also known as ultrasound, is a non-invasive imaging technique that uses high-frequency sound waves to create images of structures inside the body. In the context of a patient who is pregnant, sonography is commonly used to assess the well-being of the fetus. It allows healthcare providers to monitor the growth and development of the fetus, evaluate the placenta, amniotic fluid levels, and detect any abnormalities that may be present.

Correct Answer: C

Rationale: Chest pain, dyspnea, hypotension, and ST-segment elevation on an ECG in the inferior leads are classic signs of an acute myocardial infarction (MI). An acute MI occurs when there is a sudden blockage of blood flow to a part of the heart muscle, leading to tissue damage. This causes symptoms such as chest pain due to ischemia, dyspnea due to heart failure, and hypotension due to poor cardiac output. The ST-segment elevation seen on the ECG is indicative of significant myocardial injury. Prompt diagnosis and management are crucial in acute MI to prevent further complications and to minimize damage to the heart muscle. It is important to differentiate an acute MI from stable or unstable angina or other cardiovascular disorders, as the management and prognosis vary significantly.

Correct Answer: A

Rationale: Naloxone is a medication used to reverse the effects of an opioid overdose by binding to opioid receptors and displacing the opioids. Administering naloxone intravenously is the recommended intervention for managing a patient with a suspected opioid overdose as it can quickly reverse respiratory depression, sedation, and other effects of opioids. This intervention can be life-saving in cases of opioid overdose and is a critical step in the management of such patients. Providing respiratory support with bag-valve-mask ventilation may be necessary in addition to naloxone administration to ensure adequate oxygenation, but naloxone remains the primary intervention to reverse the effects of opioids. Encouraging the patient to drink fluids rapidly or administering benzodiazepines for sedation are not recommended interventions for managing a suspected opioid overdose.

Correct Answer: D

Rationale: Upon clinical assessment, the nurse observes that the outstanding manifestation of the patient is edema. Edema is characterized by the accumulation of excess fluid in the body's tissues, leading to swelling. Edema can be a sign of various health conditions, such as heart failure, kidney disease, liver disease, or injury. It is crucial to identify and address the underlying cause of edema promptly to prevent complications and provide appropriate treatment for the patient.

Correct Answer: A

Rationale: A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, causing increased pressure in the chest cavity. This can lead to compression of the lung and major blood vessels, leading to inadequate oxygenation and circulation.